Managing the acutely threatened airway following head and neck trauma – Requiem for cricothyroidotomy?

Abstract

• Paucity of skills to establish a surgical airway in patients presenting with head and neck trauma. • 242 patients required a surgical airway; 98% surgical tracheostomy, 2% surgical cricothyroidotomy. • The use of cricothyroidotomy in modern trauma appears to be very limited. Trauma to the head and neck results in acute facial trauma and swelling, which may occlude the airway and result in fatal hypoxia. The management is the establishment of a definitive airway. This paper reviews our experience with this clinical scenario. A retrospective study was conducted over a seven-year period from December 2012 to January 2020 at a major trauma centre in South Africa on all adult trauma patients who required a surgical airway procedure (surgical cricothyroidotomy (SC) or surgical tracheostomy (ST)). From December 2012 to January 2020, 12243 trauma patients were admitted. Of those, 242 patients required a surgical airway: 98% (238/242) underwent ST and 2% (4/242) underwent SC. A total of 3271 patients sustained trauma predominantly confined to the face and neck. The mechanism was penetrating trauma in 1077 and blunt trauma in 2194. Total of 51 patients required an emergency airway for acute head and neck trauma. There were four SC's and 47 ST's. Of the four SC, three were inserted secondary to multiple failed attempts at intubation and one was inserted directly into an open tracheal injury. All of these were performed in the resuscitation room. The 47 ST's were performed under conscious sedation in the operating theatre. There were eight failed intubations in the 51 patients with head and neck trauma, and of those three required an emergency SC and five required an emergency ST. The use of cricothyroidotomy in modern trauma care in our environment appears to be very limited.